| *Name |
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| *Date of Birth (DD/MM/YYYY) |
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| *Address |
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| *Email |
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| Telephone Number: |
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| Please describe your skin concerns and what you want to achieve |
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MEDICAL HISTORY |
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*Do you suffer from any allergies? |
Yes
No
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*Have you a history of severe allergic reaction? |
Yes
No
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*Are you currently taking any medication? |
Yes
No
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*Do you suffer from stress/anxiety attacks? |
Yes
No
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*Are you taking HRT - hormone replacement therapy? |
Yes
No
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*Are you pregnant/trying to become pregnant or breast-feeding? |
Yes
No
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*Do you suffer from asthma or any respiratory disorders? |
Yes
No
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*Are you diabetic? |
Yes
No
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*Do you suffer from any type of autoimmune disease e.g. Lupus? |
Yes
No
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*Do you suffer from any active skin conditions e.g. psoriasis, eczema? |
Yes
No
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*Do you suffer from urticaria or have a history of skin rashes? |
Yes
No
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*Do you suffer from herpes simplex virus i.e. cold sores? |
Yes
No
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| If you answered YES to any questions please give further information or if have any other relevant medical history of note including operations and treatments please specify |
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SKIN HISTORY |
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*Do you currently use any retinol/vitamin A based products? |
Yes
No
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*Are you using any glycolic based products? |
Yes
No
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*Have you used Accutane (Roaccutane) within the last 6 months? |
Yes
No
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*Are you sensitive to alcohol based skin products? |
Yes
No
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*Have you ever had a skin reaction from any skin products? |
Yes
No
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*Do you suffer with hyper or hypo pigmentation changes of the skin (Loss of pigment)? |
Yes
No
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*Do you have a history of keloid/hypertrophic scarring ? |
Yes
No
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*Have you recently undergone any facial laser treatments? |
Yes
No
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*Have you ever had any form of laser treatment? |
Yes
No
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*Have you recently had any facial waxing/depilatories/electrolysis? |
Yes
No
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*Have you recently used a sunbed or sunbathed? |
Yes
No
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*Do you use fake sun tan on your face? |
Yes
No
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*Do you tan easily? |
Yes
No
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| If you answered YES to any of the previous questions please give further information |
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| *Describe you daily skin care routine |
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| * What skin care products do you normally use? |
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| * Are there any particular skin products / brands you are interested in using? |
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| * I confirm that I have completed my medical history in full and understand that failure to declare all of my medical history details may result in failure of the treatment/products and increase the risk of possible complications |
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* I have been offered a face to face consultation by Face the Future Ltd but have opted to waive my right to this consultation. I agree to follow the instructions provided by my heath care professional (authorised by Face the Future Ltd) and to contact the Clinic in the first instance if there are any queries or concerns regarding product usage. |
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I confirm that what I have typed above should be taken as my legal signature on behalf of Face the Future Ltd.
Today's Date:
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